It would appear that the vessel touched bottom directly off Four Mile Point and continued for approximately 100 m before turning to starboard away from land. When the CGR 100 arrived on scene, the Sunrise V was 460 m offshore in position 43 15.75' N, 079 07.85' W. However, reports originating from the vessel placed the position of the striking 255 m further downwind to the north-east. the effect of a strong south-westerly wind on the drifting vessel during the 27minutes between the time of the incident and the arrival of the SAR unit; the recorded water depths; and the vessel's relatively shallow foil-borne draught of 1.1m, it is probable that the vessel touched bottom somewhat closer to the shoreline than reported by the vessel (see Appendix A). Although the master has overall command of the vessel, a basic premise of modern safety management is that shore management has the ultimate responsibility for setting policies, procedures, and operating instructions for the safe operation of the entire enterprise. Introduction of a safety management system requires that a company develop and implement safety management procedures to ensure that conditions and activities, both ashore and afloat, affecting safety and environmental protection are planned, executed and checked in accordance with regulatory and company requirements. A structured system also enables the company to focus on the enhancement of safe ship operations and on preparing for emergencies. Companies which are successful in establishing a safety management system may expect to see a reduction in accidents that could cause injuries to people, or damage to property and the environment. Depending on their geographical location, two differing standards apply to high-speed craft in Canada. TCMS does not apply the provisions of the HSC Code to high-speed vessels operating in the Great Lakes, and instead utilizes the less stringent DSC Code. As a result, companies operating high-speed craft in the Great Lakes are not required by TCMS to have safety management systems in place. For the Sunrise V, the establishment of a safety management system incorporating company procedures for voyage planning, on-board provision of proper charts/publications, ensurance that all crew members are qualified and the practice of bridge resource management, may have provided additional guidance and warnings to the master to avoid the dangers to navigation in the Four Mile Point area. Direct crossings of Lake Ontario in good weather did not present any undue risk. However, on the evening of the occurrence, the waves on Lake Ontario were too high for a return voyage to Toronto and the company did not have procedures in place to guide the master as to where he should berth the vessel for the night. However, several options were available to him. Stay in Lewiston for the night and reposition the vessel to Port Dalhousie the next morning. Stay in Niagara-on-the-Lake for the night and reposition the vessel to Port Dalhousie the next morning. Continue on to Port Dalhousie immediately, taking a course close inshore to avoid the weather. These options can be viewed in terms of gains and losses: Option A) Gain: the vessel would be safe for the night. Loss: the master and crew would have to sleep aboard the vessel (only 2 berths) and rise early the next morning. It was possible that their arrival in Port Dalhousie would be delayed. Option B) Gain: the vessel would have covered part of the distance to Port Dalhousie within the sheltered estuary of the Niagara River. Loss: the dock in Niagara-on-the-Lake is exposed to weather and currents. Option C) Gain: the vessel would be repositioned for the scheduled voyage from Port Dalhousie to Toronto the following morning. The master would have been able to sleep at home overnight and get up at a normal time for work. Loss: skirting the shoreline in shallower water involves more diligent navigation and runs the risk of going aground. Knowledge of human behaviour tells us that when people find themselves in a situation where they must solve a problem to which no rules apply and a new solution or plan must be formulated, there may be a tendency to frame the problem as a choice between gains and losses. With respect to losses, people are biased towards choosing the risky loss, which is potentially more disastrous, but less probable, than the certain loss. Although skirting the shoreline while continuing on to Port Dalhousie had a potentially higher loss (more disastrous consequence), the loss was seen as less probable than the certain losses (sleeping on the vessel, repositioning after sunrise, arriving late in Port Dalhousie). Without the guidance given by formal company procedures derived from a safety management system (based upon sound risk management principles), the master chose to deliver the vessel to Port Dalhousie along a route passing over the shoal at Four Mile Point. Nautical publications provide information critical to safe navigation and they must be referred to on board. Contrary to the Charts and Nautical Publications Regulations, the small scale of the chart (L/C 2077 ) carried on board did not provide sufficient detail of the area around Four Mile Point for the operator to be aware of the existence of the boulders on the lake bottom. Also, no provisions for readily displaying a chart were available on the bridge. As a result, the master did not have adequate charted information at his disposal or a facility on which to determine his position in relationship to the hazards off Four Mile Point. The master was not trained in BRM and the first mate, who was not on the bridge at the time of the occurrence, did not possess a certificate of competency. Without a qualified mate to assist the master with the navigation of the vessel under difficult circumstances, the chances of a successful near-to-shore passage between the Niagara River estuary and Port Dalhousie were reduced. Special precautions should be taken by high-speed craft travelling in the vicinity of shallow waters. The DSC Code requires that vessels be fitted with a depth-sounder for use when operating in displacement mode (during docking or in shallow areas when the submerged foils could touch bottom). Because of interference caused by water flow past the hull, depth-sounders become less effective at higher speeds, and dangers such as the rapidly shoaling water and boulders at Four Mile Point cannot be readily detected. Had the Sunrise V been equipped with a depth-sounder used effectively with the vessel operating at slower speeds, navigation around the shoal areas at Four Mile Point may have been easier to achieve safely. Also a depth-sounder would have been useful after the occurrence to avoid all hands being used for poling water depths over the side, thereby allowing someone to stand watch on the bridge and respond to SAR radio signals. Fatigue may be described as a physiological state typically caused by an inadequate quantity or quality of sleep and characterized by impaired performance and diminished alertness. Although the master may not have been in a state of sleep deprivation, he may have suffered from fatigue as result of poor quality sleep obtained while napping in passenger seats between voyages, or while sleeping on board the previous night.Analysis It would appear that the vessel touched bottom directly off Four Mile Point and continued for approximately 100 m before turning to starboard away from land. When the CGR 100 arrived on scene, the Sunrise V was 460 m offshore in position 43 15.75' N, 079 07.85' W. However, reports originating from the vessel placed the position of the striking 255 m further downwind to the north-east. the effect of a strong south-westerly wind on the drifting vessel during the 27minutes between the time of the incident and the arrival of the SAR unit; the recorded water depths; and the vessel's relatively shallow foil-borne draught of 1.1m, it is probable that the vessel touched bottom somewhat closer to the shoreline than reported by the vessel (see Appendix A). Although the master has overall command of the vessel, a basic premise of modern safety management is that shore management has the ultimate responsibility for setting policies, procedures, and operating instructions for the safe operation of the entire enterprise. Introduction of a safety management system requires that a company develop and implement safety management procedures to ensure that conditions and activities, both ashore and afloat, affecting safety and environmental protection are planned, executed and checked in accordance with regulatory and company requirements. A structured system also enables the company to focus on the enhancement of safe ship operations and on preparing for emergencies. Companies which are successful in establishing a safety management system may expect to see a reduction in accidents that could cause injuries to people, or damage to property and the environment. Depending on their geographical location, two differing standards apply to high-speed craft in Canada. TCMS does not apply the provisions of the HSC Code to high-speed vessels operating in the Great Lakes, and instead utilizes the less stringent DSC Code. As a result, companies operating high-speed craft in the Great Lakes are not required by TCMS to have safety management systems in place. For the Sunrise V, the establishment of a safety management system incorporating company procedures for voyage planning, on-board provision of proper charts/publications, ensurance that all crew members are qualified and the practice of bridge resource management, may have provided additional guidance and warnings to the master to avoid the dangers to navigation in the Four Mile Point area. Direct crossings of Lake Ontario in good weather did not present any undue risk. However, on the evening of the occurrence, the waves on Lake Ontario were too high for a return voyage to Toronto and the company did not have procedures in place to guide the master as to where he should berth the vessel for the night. However, several options were available to him. Stay in Lewiston for the night and reposition the vessel to Port Dalhousie the next morning. Stay in Niagara-on-the-Lake for the night and reposition the vessel to Port Dalhousie the next morning. Continue on to Port Dalhousie immediately, taking a course close inshore to avoid the weather. These options can be viewed in terms of gains and losses: Option A) Gain: the vessel would be safe for the night. Loss: the master and crew would have to sleep aboard the vessel (only 2 berths) and rise early the next morning. It was possible that their arrival in Port Dalhousie would be delayed. Option B) Gain: the vessel would have covered part of the distance to Port Dalhousie within the sheltered estuary of the Niagara River. Loss: the dock in Niagara-on-the-Lake is exposed to weather and currents. Option C) Gain: the vessel would be repositioned for the scheduled voyage from Port Dalhousie to Toronto the following morning. The master would have been able to sleep at home overnight and get up at a normal time for work. Loss: skirting the shoreline in shallower water involves more diligent navigation and runs the risk of going aground. Knowledge of human behaviour tells us that when people find themselves in a situation where they must solve a problem to which no rules apply and a new solution or plan must be formulated, there may be a tendency to frame the problem as a choice between gains and losses. With respect to losses, people are biased towards choosing the risky loss, which is potentially more disastrous, but less probable, than the certain loss. Although skirting the shoreline while continuing on to Port Dalhousie had a potentially higher loss (more disastrous consequence), the loss was seen as less probable than the certain losses (sleeping on the vessel, repositioning after sunrise, arriving late in Port Dalhousie). Without the guidance given by formal company procedures derived from a safety management system (based upon sound risk management principles), the master chose to deliver the vessel to Port Dalhousie along a route passing over the shoal at Four Mile Point. Nautical publications provide information critical to safe navigation and they must be referred to on board. Contrary to the Charts and Nautical Publications Regulations, the small scale of the chart (L/C 2077 ) carried on board did not provide sufficient detail of the area around Four Mile Point for the operator to be aware of the existence of the boulders on the lake bottom. Also, no provisions for readily displaying a chart were available on the bridge. As a result, the master did not have adequate charted information at his disposal or a facility on which to determine his position in relationship to the hazards off Four Mile Point. The master was not trained in BRM and the first mate, who was not on the bridge at the time of the occurrence, did not possess a certificate of competency. Without a qualified mate to assist the master with the navigation of the vessel under difficult circumstances, the chances of a successful near-to-shore passage between the Niagara River estuary and Port Dalhousie were reduced. Special precautions should be taken by high-speed craft travelling in the vicinity of shallow waters. The DSC Code requires that vessels be fitted with a depth-sounder for use when operating in displacement mode (during docking or in shallow areas when the submerged foils could touch bottom). Because of interference caused by water flow past the hull, depth-sounders become less effective at higher speeds, and dangers such as the rapidly shoaling water and boulders at Four Mile Point cannot be readily detected. Had the Sunrise V been equipped with a depth-sounder used effectively with the vessel operating at slower speeds, navigation around the shoal areas at Four Mile Point may have been easier to achieve safely. Also a depth-sounder would have been useful after the occurrence to avoid all hands being used for poling water depths over the side, thereby allowing someone to stand watch on the bridge and respond to SAR radio signals. Fatigue may be described as a physiological state typically caused by an inadequate quantity or quality of sleep and characterized by impaired performance and diminished alertness. Although the master may not have been in a state of sleep deprivation, he may have suffered from fatigue as result of poor quality sleep obtained while napping in passenger seats between voyages, or while sleeping on board the previous night. Due to adverse weather encountered on Lake Ontario, the Sunrise V was prevented from completing her remaining scheduled voyages across the lake. The vessel was required to be in Port Dalhousie the following morning for a departure at 0700. The master chose to take a more sheltered inshore route to Port Dalhousie, by skirting the shoreline over a dangerous shoal area strewn with boulders off Four Mile Point. The master was alone on the bridge during the passage from the Niagara River towards Port Dalhousie. The vessel was in high-speed foil-borne mode when she was steered too close to shore and made contact with a submerged object off Four Mile Point. When the SAR unit arrived on scene, the vessel was disabled in a position 460m from shore. The shoal area extends offshore for 550m. The nautical chart on board did not show details of the lake bottom in the vicinity of Four Mile Point. A larger scale chart of the area exists (CHS No 2043), but it was not on board. At the time of the occurrence, there was no easy means of referring to charted information at the conning position. A detailed passage plan had not been prepared and the vessel's position was not being plotted as she proceeded along the shoreline towards Port Dalhousie. The master's recorded position of the vessel at the time of bottom contact was inconsistent with the location of the vessel when the SAR unit arrived on scene. The vessel is not equipped with a depth-sounder. The company did not have a safety management system in place giving detailed operating procedures, including recommended sailing routes. Bridge resource management was not practised between master and mate. The mate was not on the bridge to assist the master during the passage from the Niagara River towards Port Dalhousie. The mate held no formal marine qualifications.Findings Due to adverse weather encountered on Lake Ontario, the Sunrise V was prevented from completing her remaining scheduled voyages across the lake. The vessel was required to be in Port Dalhousie the following morning for a departure at 0700. The master chose to take a more sheltered inshore route to Port Dalhousie, by skirting the shoreline over a dangerous shoal area strewn with boulders off Four Mile Point. The master was alone on the bridge during the passage from the Niagara River towards Port Dalhousie. The vessel was in high-speed foil-borne mode when she was steered too close to shore and made contact with a submerged object off Four Mile Point. When the SAR unit arrived on scene, the vessel was disabled in a position 460m from shore. The shoal area extends offshore for 550m. The nautical chart on board did not show details of the lake bottom in the vicinity of Four Mile Point. A larger scale chart of the area exists (CHS No 2043), but it was not on board. At the time of the occurrence, there was no easy means of referring to charted information at the conning position. A detailed passage plan had not been prepared and the vessel's position was not being plotted as she proceeded along the shoreline towards Port Dalhousie. The master's recorded position of the vessel at the time of bottom contact was inconsistent with the location of the vessel when the SAR unit arrived on scene. The vessel is not equipped with a depth-sounder. The company did not have a safety management system in place giving detailed operating procedures, including recommended sailing routes. Bridge resource management was not practised between master and mate. The mate was not on the bridge to assist the master during the passage from the Niagara River towards Port Dalhousie. The mate held no formal marine qualifications. The Sunrise V was steered too close to shore at foil-borne speed when she made contact with a submerged object in an area of shoal and boulders extending from Four Mile Point. Contributing to the occurrence were the absence of a suitable nautical chart of the immediate area, non-fulfillment of the normal practice of plotting the vessel's position during the voyage, failure of the master to utilize the mate's assistance on the bridge, lack of a depth-sounder for use at slower speeds and of a company safety management system to encompass procedures for voyage planning, cancellations and emergency situations.Causes and Contributing Factors The Sunrise V was steered too close to shore at foil-borne speed when she made contact with a submerged object in an area of shoal and boulders extending from Four Mile Point. Contributing to the occurrence were the absence of a suitable nautical chart of the immediate area, non-fulfillment of the normal practice of plotting the vessel's position during the voyage, failure of the master to utilize the mate's assistance on the bridge, lack of a depth-sounder for use at slower speeds and of a company safety management system to encompass procedures for voyage planning, cancellations and emergency situations. Safety Action Action Taken Safety Management Systems The operations of high-speed vessels are more demanding than that of conventional vessels and accidents have a greater potential to result in serious damage and injuries. The HSC Code recognizes this fact and requires that companies operating high-speed craft have in place a quality management system. Furthermore, it cautions that the code is a unified document and administrations should apply all sections because non-compliance with any part of the Code could result in an imbalance which would adversely affect the safety of the craft, passengers and crew.7 Contributing to the occurrence was a lack of formal procedures which would be inherent in a formal safety management system. As a result, the TSB issued Marine Safety Advisory (MSA) No 02/99 to apprise TC of the need for safety management systems to be in place within companies operating high-speed craft before the vessels are placed in service. Availability of Charts at the Conning Position on High-speed Craft Following an occurrence involving a collision between the conventional ferry Queen of Saanich and the high-speed ferry Royal Vancouver in 1992, the TSB issued MSA No 09/92 advising TCMS that no navigational charts were available at the conning station of the Royal Vancouver, and that the existing chart table was not large enough to accommodate standard nautical charts. While there was a chart available, there was no easy means of displaying charted information at the conning position of the Sunrise V and no chart was being used at the time of the occurrence. As a result, in January 1999 TCMS amended its Notices to Surveyors, advising inspectors to ensure that navigational charts, including those used in conjunction with any electronic charts such as ECDIS, are in a suitable format (such as strip charts or flip charts) and located so that the navigating officer at the conning station has the facility to readily refer to them. Certification of Vessel As a result of several incidents involving high-speed craft operations, and the Sunrise-type of hydrofoils in particular, TCMS initiated a review of all such operations on Lake Ontario. As a result, the Sunrise-type of hydrofoils will no longer be certified for unrestricted Great Lakes voyages. TC Inspection Procedures As a result of the review of high-speed craft operations, the Ontario regional manager issued instructions to ensure that the following items are implemented prior to a certificate or permit being issued: The on-board operations manual is to be reviewed for completeness and to ensure that it includes adequate operational and maintenance instructions that are consistent with a quality management system. A warning is to be posted in the wheel-house regarding the dangers of operating in shallow or hazardous waters. The certificate must be endorsed with the requirement for the vessel to exchange information on adverse changes in weather conditions with all high-speed vessels in the vicinity. TCMS will put forward for national consideration and development the recommendations that: Specific marine qualifications for this class of vessel be developed. A syllabus be prepared outlining crew training. Appropriate Canadian inspection certificates and permits be developed, as required by the Code of Safety for Dynamically Supported Craft.